Women's Transitional Living Program Referral Packet - Updated February 2021 816 HWY 22 - The ...
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Women’s Transitional Living Program
Referral Packet
Updated February 2021
The Mountain Center
816 HWY 22
PO Box 1239
Peña Blanca, New Mexico 87041
Intake: (505) 465-2040 Ext. 12
Fax: (505) 465-1336
tenasha@themountaincenter.org
Web: themountaincenter.orgHello! This is the first step of admission into our transitional living program at The Mountain Center (TMC). This is our referral packet that is filled and signed by licensed professionals as well as the client being admitted. All sections of this document are critical as it best informs us on whether or not the client is a fit for our program and ultimately be able to provide the best care for the client. About Us - The transitional living facility at The Mountain Center was established in 2015 as a project of Interfaith LEAP, Inc., a 501 (c) 3 nonprofit organization. Our purpose is to offer a safe and sober transitional living space for women recovering from substance use disorders. The Mountain Center is the “place between” residential programs and communities that may not be recovery-friendly enough to support any stage of a woman’s recovery journey. Here, we’re able to meet other needs of recovering women, build life skills, explore how to balance employment and recovery and grow the spiritual strength for long-term recovery. We work with recovering women to build on their skills and bring them back into the community to live a more resilient and healthier life. About the referral process - The following is mandatory before anyone can be admitted. ❏ A current COVID-19 test result that is negative ❏ Client confirmation that they have been in quarantine while waiting for results ❏ Authorization for Release of Information (completed and signed by a Licensed professional) ❏ Current Medical Clearance for Participation (completed and signed by a Licensed professional) ❏ Standing Order for “Bedside” Medication (completed and signed by a Licensed professional) ❏ Behavioral Health Information and Clearance (completed and signed by a Licensed professional) ❏ Client Intake Questionnaire (completed by client) Below is the Screening Requirements Checklist which will have additional information that will be needed for admission. Please let us know if you have any questions. Thank you, Tenasha Ansera Client Services Coordinator PH. 505-465-2040 C. 505-453-4456 The Mountain Center 816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 1
Screening Requirements Checklist
Note: The Mountain Center is a 3-month (90 days) residential program intended to provide a safe, structured,
supportive environment during the woman's transition to stable, community-based recovery. Length of stay is
determined by an individual treatment plan. It is not intended as a substitute for residential addiction treatment
or a detox center.
✔ REQUIREMENTS Date
Received
1. Stable early recovery, as evidenced by successful completion of a recommended SUD
treatment program, a substantial period of abstinence in a controlled setting, or the
equivalent. Must be completely detoxified.
2. Signed Authorization for Release(s) of Information to ensure coordination of services with
other providers or authorities involved in the case.
3. Current Medical Clearance for Participation signed by qualified licensed healthcare
practitioner (MD/Nurse Practitioner). Submission must be no longer than (2) two weeks
prior to her entering our program.
4. Included in Medical Clearance: TB test and result
5. Included in Medical Clearance: HIV test and result
6. Included in Medical Clearance: Hepatitis A, B, C tests and results
7. Included in Medical Clearance: Behavioral Health Information including current medications
signed by a qualified licensed mental health or psychiatric provider.
8. Standing Order OTC Medication Form (must be completed and signed by a
Licensed Healthcare Practitioner)
9. Complete Standing Order for “Bedside” Medication Self-Administration (i.e., use of an
Inhaler or EPI-PEN)- (if applicable) (must be completed and signed by a Licensed
Healthcare Practitioner)
10. 30 day supply of medications must be in the original container from
pharmacy/current prescription with refills as indicated (if applicable). Please note:
Controlled Medications will not be accepted.
11. Psychological or psychiatric evaluation (if applicable)
12. Information on most recent course of treatment (from the provider).
13. Any combination of the following evaluations (must be dated within six months of
potential admission)
● Clinical Interview completed by a licensed therapist
● Biopsychosocial History
● Mental Health Screening
● Other types of screening tools – SASSI, Beck Depression, etc.
14. Intake questionnaire completed by potential applicant
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 215.Court Order, Probation/Parole Plan, Charges, Pending (if applicable)
16.Copy of Social Security Card
17.Copy of Identification Card or Valid Driver’s License
18.Copy of Medicaid Card (if applicable)
19.Certificate of Indian Blood and Tribal ID card (if applicable)
20.Other pertinent information (CYFD safety plan / treatment plan of family plan)
21. Copy of COVID-19 test result
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 3Authorization for Release of Information
I, (print name) _________________________________________________________
Date of birth: ________________________ Social Security #: ___________________
I hereby agree for reciprocal information to be obtained and release to The Mountain Center to and from
Agency/Provider: _____________________________________________________
Address: ____________________________________________________________
Telephone: _____________________ Fax: __________________
Email: ________________________________________________
I do release The Mountain Center from any and all legal liabilities that may arise from the release of this
information pursuant to Evaluation/Assessment and or other coordination and case management
treatment efforts on my behalf:
◻ Assessment Report ◻ History/Intake ◻ Medication History
◻ Treatment Summary ◻ Treatment Plan ◻ Discharge Summary
◻ Medical Information ◻ Treatment ◻ Judicial/Courts /Probation/Parole
Recommendations
◻ Psychological Evaluation/Test Results ◻ Diagnostic Report
◻ Other: ____________________________________________________________________________
____________________________________________________________________________________
I understand that information regarding my alcohol and / or drug treatment is protected by federal law under the Drug
Abuse Prevention, Treatment, and Rehabilitations Act and the privacy provisions of the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA"), and their implementing regulations. See 42 C.F.R. Part 2; 45 C.F.R. Parts 160,
164. I understand that my health information specified above will be disclosed pursuant to this authorization, that the
recipient of the information may re-disclose the information and it may no longer be protected by federal law under
HIPAA. Federal law governing confidentiality of alcohol and drug abuse patient information noted above, however, will
continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program. I
understand that I may revoke this consent in writing at any time except to the extent that action has been taken in
reliance on it, and that this consent will expire in one (1) year unless otherwise specified below:
Specify below the date, event or condition upon which this consent expires:________________
I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to
the extent that the information has already been released):
Authorizing Signature: ___________________________________ Date:_____________
Witness:_______________________________________________ Date:_____________
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 4Medical Clearance
Patient Name:________________________________________ Date of Examination: _________________
DOB: _____________________ LAST ETOH/DRUG USE: _____________________________________
Height: _____________ Weight: _____________B/P: ______________ HEENT:
Current Medication/Dosage_____________________
Chest:___________________________________________________________________________________
Heart:___________________________________________________________________________________
Abdomen:________________________________________________________________________________
Genitourinary:____________________________________________________________________________
Extremities:______________________________________________________________________________
Neurologic:______________________________________________________________________________
Laboratory Data:
Hepatitis Test for A, B, C Date obtained: ________Results: A_________ B________C________
HIV Test__________ Date Obtained:___________________ Results_________________________
SMAC: _________________ RPR______________ HCT: ______________ UA: _______________
Current Tuberculin Skin Test: Placed: _____________Read____________Result: ____________
Pregnant? Yes [ ] No [ ] Gestation_________________Weeks
Current Medication/Dosage (what and what are the side effects?)
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
4. ______________________________________________________________________________
Allergies
Medications: ______________________________________________________
Food: ____________________________________________________________
Environmental: ____________________________________________________
Other: ___________________________________________________________
Does the patient have Epinephrine Yes [ ] No [ ]
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 5Medically Stable, is able to participate in transitional living program without restrictions: Yes [ ] No [ ]
Physically Stable, is able to participate in transitional living program without restrictions: Yes [ ] No [ ]
Note
Restrictions:__________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Signature of Licenced Medical Provider:___________________________________________________
Physician’s Name:______________________________________________Phone: ____________________
Clinic: ___________________________________________________
Address: __________________________________________________
Email:____________________________________________________
*Please complete the attached Standing Order(s) for OTC & Bedside Medication Self-Administration.
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 6Standing Order
OTC Medication Self-Administration
Resident Name_______________________________________
DOB:_______________________ File Number:____________________
The Mountain Center (TMC) permits resident self-administration of Over-the-Counter (OTC) medications as
authorized by a licensed healthcare practitioner. This document represents a Standing Order for this resident that shall
remain in effect during her stay at TMC unless otherwise indicated. TMC provides limited OTC meds for temporary
relief of symptoms. They are not intended to substitute for medical treatment. Residents are instructed to seek medical
attention if there appears to be either a sensitivity reaction or significant side effects, or when relief is not forthcoming
within a reasonable time-frame.
Please write out a detailed order which includes:
1. Symptoms to be addressed
2. Dose, frequency, schedule of administration
3. Maximum total dose per 24 hours
4. Period medication is to be used
5. ANY KNOWN MEDICATION ALLERGIES (IF APPLICABLE)
6. IF THIS INDIVIDUAL IS NOT TO USE ONE OR MORE OF LISTED MEDICATIONS
ALLERGIC TO:
Please Check/or note below:
Acetaminophen 500mg/Ibuprofen 200 mg – Per Manufacturer’s Instructions □
Or______________________________________________________________________________________
Aluminum/Magnesium 225 mg/200 mg Liquid Antacid – Per Manufacturer’s instructions □
Or_______________________________________________________________________________________
Guaifenesin Cough Syrup – Per Manufacturer’s Instructions □
Or______________________________________________________________________________________
Pepto-Bismol – Per Manufacturer’s Instructions □
Or______________________________________________________________________________________
Antacid tablets – Per Manufacturer’s Instructions □
Or______________________________________________________________________________________
Cough drops – Per Manufacturer’s Instructions □
Or______________________________________________________________________________________
Signature of Licensed Medical Practitioner____________________________________________
Date________________
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 7Standing Order for “Bedside” Medication
Self-Administration To Whom It May Concern:
The Mountain Center provides residents with self-administration of medication. This individual is required
to obtain a BEDSIDE order for medication from a Licensed Practitioner in order to adhere to the
self-administration procedure.
Please Note: The BEDSIDE order is applicable only to individuals who have been educated in the use of
any bedside medications prescribed i.e., use of an INHALER or EPI-PEN. This order will allow this
individual to maintain the medication on their person and in their possession at all times.
The BEDSIDE order pertaining to this resident will remain in effect for the duration of her stay. Residents
will seek medical attention when appropriate, i.e., if there appears to be either a sensitivity reaction,
significant side effects or when relief is not obtained.
PLEASE NOTE ANY KNOWN ALLERGIES TO MEDICATION:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please describe in detail below which includes:
1. For what symptoms: ___________________________________________________________
2. An exact dose: _______________________________________________________________
3. A maximum total dose per 24 hours: ______________________________________________
4. Instructions on what to do if symptoms persist: ______________________________________
The Bedside Order applies only to the medication(s) below:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Signature of Licensed Medical Practitioner____________________________ Date__________
Patient______________________________________ DOB_________________
File NO:______________
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 8Behavioral Health Information and Clearance
TO BE COMPLETED BY A LICENSED BEHAVIORAL HEALTH PROVIDER
Name of Client: ____________________________________________ Date: __________________________
DOB: ______________ Last 4 Digits of SSN: ______________________ Last ETOH/Drug Use: _________________
DIAGNOSES:
PRIMARY: _______________________________________________________________________________
SECONDARY: ____________________________________________________________________________
Current Medications/Dosage/Rx Orders:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Stable on Medication? [ ] Yes [ ] No Has the client been suicidal in the last two months? [ ] Yes [ ] No
Client is mentally stable and able to participate in a transitional living program such as The Mountain Center without
restrictions [ ] Yes [ ] No
Note Restrictions: _________________________________________________________________________
Please attach any combination of the following evaluations (must be dated within six months of referral)
❏ Psychological or Psychiatric Evaluation ❏ Clinical Interview (by a licensed therapist)
❏ Biopsychosocial History ❏ Mental Health Screening
❏ Other Types of Screening Tools Other:
❏ ASI ❏ __________________________
❏ SASSI
❏ Back Depression ❏ __________________________
Information on most recent course of treatment:
___________________________________________________________________________________________
___________________________________________________________________________________________
Signature of Licenced Clinical Provider:_______________________________________________________
Name of Licenced Clinical Provider:______________________________ Phone: ____________________
Clinic:____________________________________________________________________________________
Address: __________________________________________________________________________________
Email:____________________________________________________
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 9The Mountain Center
Client Intake Questionnaire
(TO BE COMPLETED BY APPLICANT)
Please Print Clearly
Name: ______________________________________________ Date of Birth: _____________________
Today’s Date: _____________________________
1. What problems/difficulties were going on in your life that caused you to seek help at TMC? (Include any legal, family, social,
employment, or other issues that influenced your decision.)
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2. Are you currently receiving any mental health services? If yes, please describe.
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
____________________________________________________________________________________________________________
3. Are you currently experiencing feelings of depression or anxiety, or thoughts of harming yourself or others? If yes, please
describe.
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
____________________________________________________________________________________________________________
4. Please list any prior treatment episodes. Please include the name of the program or provider, and the approximate date, length of
stay, and whether you completed treatment.
Mental Health treatments (please list dates you discharged)
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
____________________________________________________________________________________________________________
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 10Substance Abuse treatment (please list dates you discharged)
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Have you taken any medications in the last 2 weeks? What medications are currently prescribed for you? If you can, list the Medication
Name, Dose, and Frequency of each.
Medication Name Dosage Frequency
5. Medical & Healthcare History:
(Circle all conditions that apply)
Been hospitalized Had surgery in last 5 years
Treated after serious accidents Treated for head injury
Treated for neurological problems Treated for heart problems
Treated for respiratory problems Treated for diabetes
Had unusual gains or losses of weight Stomach problems
Any difficulty with sleep Changes in eating patterns
Skin problems Fractured Bone or Joint problems
Communicable disease Urinary problems
Had a sexually transmitted disease Difficulties with sexual functioning
Reproductive difficulties Hearing problems
Vision problems Had activities restricted due to health problems
Brain Injury/loss of consciousness
Other _________________________
Please Check All That Apply
❑ Any special dietary restrictions? (i.e. vegetarian/vegan/gluten free/lactose intolerant?) ________________________
❑ Asthma? Is it mild/moderate/severe? Do you carry an inhaler? ___________________________________________
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 11❑ ALLERGIES to medicines, foods, materials, or insect bites (please describe)? Do you carry epinephrine? _________
❑ Is there anything we should know with your health that we should know about that was not mentioned?
___________________________________________________________________________________________
___________________________________________________________________________________________
Date of last menstrual cycle: _________________________________
Are you or do you feel you might be pregnant? Yes____ No____
Number of previous pregnancies _______ Live births: _______ Living children________
6. Children
Please list the name and ages of your children and with whom they reside at present:_________________
CYFD or Tribal Social Services Involved? Yes____ No____ Name of Providers____________________
7. Substance Use (list all substances used, number of days used in previous month, how used, and age at 1st use)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
8. Is there a history of substance abuse in your family? If yes, please describe.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
9. History of Mental Health Diagnosis?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 1210. Criminal Activity? Yes____ No____ If yes, what was your last chage and date? ____________________ Have you ever been incarcerated? If yes, for what, where, when, and for how long? _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Are you currently on probation or parole? Yes____ No____ If yes, for what offenses? ____________________________________________________________________________________________________ Was it for Violent Behavior? If yes, please describe: ____________________________________________________________________________________________________ Client Signature: ________________________________________ Date: _____________________ The Mountain Center 816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 13
What to bring with you to The Mountain Center
● Current driver’s license or photo ID (or we can't admit you.)
● A 30-day supply of any prescribed medication you're taking, with refills. If this is not possible, please bring in a
written prescription so that it may be filled upon arrival.
● A copy of Medical Clearance and TB test results. The Medical Clearance form must be filled and signed by your
Physician and dated within 10 days of your admission. Please note that admission is not possible without a
completed Medical Clearance. Your TB test results must be negative and up-to-date (meaning less than a year old).
Results of testing for Hepatitis C may be pending, although the test date must be noted on the Medical Clearance
form.
● Outside Appointments: Please complete or reschedule any appointments, personal business, court hearings,
etc... BEFORE entering the program. TMC staff will help you keep needed appointments current.
And don't forget an adequate supply of items, and back-up for your extended stay
Bring Your Medicaid Card if applicable (including for your children, if any are coming with you)
● Social Security Card
● EBT card
● 1-2 Notebooks for education
● Pens and/or pencils, colored pencils if desired
● Stamps and envelopes for communicating with family
● Laundry soap.
● Spending money (you may have $10 on your person at any one time.)
Hygiene Items
● At least four towels and washcloths (scrubbies are allowed)
● Your favorite brand of soap
● Toothbrush and Toothpaste
● A razor
● Deodorant
● Comb and/or brush
● Hair spray (must be alcohol- free -- check the label)
Clothing Items
● Plastic Hangers (enough for your clothing that should be hung).
● 1 jacket, 2 sweatshirts, or a sweater (even in the summer, desert nights can be cool)
● 3-4 pair of sweatpants
● 5-7 pairs of Jeans or casual pants, including shorts if needed.
● 7-10 Shirts (No "spaghetti straps" or low-cut/ revealing blouses. No see-through.)
● Socks
● Shower shoes/flip-flops
● Slippers
● Robe
● Underwear
● Bras
● Pajamas
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 14● 1 pair walking shoes
Optional Items
● Books or other reading material (should be recovery-oriented)
● Hat or cap (it gets sunny)
Please Do NOT Bring
● Cell phone (you will not be permitted to use it)
● Jewelry Perfume and/or cologne are not allowed
● Knives/weapons
● Computer
● Camera
● Video Devices
● Bleach
● Personal gaming devices (PSP, Nintendo DS, etc...)
● ANYTHING that connects to the internet via Wi-Fi
● Clothing or personal items that have drug/alcohol/or sexual references, gang logos, etc...
● Pornography
● Hair Dye
● Food of any kind. We have plenty.
And Remember...
IF YOU'RE PREGNANT, LET STAFF KNOW IMMEDIATELY!
Additionally:
● A urine analysis (UA) and breathalyzer test (BA) will be required before admission can occur.
● Please, make your transportation aware that they will need to stay until the results of your UA and BA have been
admitted.
● There will be no phone calls for the first 14 days of your stay, unless there is an emergency.
● If the Medical Clearance is incomplete, you will not be admitted.
● Please stay in touch with the Admissions Coordinator to confirm your arrival time and date.
● Transportation is not provided for admission to our facility or at discharge. Please make transportation
arrangements.
If you have any questions or concerns regarding your admission, please feel free to call the Admissions Coordinator,
Monday through Friday, 8:30-5:00 at 505-465-2040, extension 12
The Mountain Center
816 HWY 22 PO Box 1239 Peña Blanca, New Mexico 87041 15You can also read
